Narrow networks are designed to keep costs down through careful selection of providers using various criteria (some pertaining to quality) for who is allowed membership in the network. In the post-acute care arena, these membership criteria often derive from public data.

There are limitations to the public data (think Five-Star Ratings, but I could go on). The Five-Star nursing home system recently underwent major revisions, adding additional quality metrics and rebasing the system, resulting in Five-Star scores that cannot be compared to previous scores (and have weak correlations to rehospitalization rates).

Many network builders use Five-Star as a gatekeeper to narrow networks. Suddenly, the new definition of “top performers” caused a shift in narrow network membership.

Basing a narrow network on public data like Five-Star is like using a paper roadmap from 1978 when you have a GPS available. These data and metrics assume all residents and all SNFs are the same. On the aggregate, a SNF can score high marks in whatever metric you choose, but that SNF might have no proficiency in diabetes care or congestive heart failure, for example. A low-risk resident can quickly become high-risk in the wrong facility, even a “preferred facility,” and that’s just not smart.

Blogger comment:

Stephen’s analogy of the roadmap versus GPS is right on.  The CMS five star rating systems are flawed.  Using the current five star ratings is like gauging quality of a car by its lack of gas, past inspections and lack of engine horse power that have no relationship to safety, quality of performance or future costs.  Unfortunately the Trade Associations have not been successful in getting an input based five star rating system to an outcome based rating.  And it will hurt setting up meaningful relationships with ACO’s, hospital networks by using quality measures that in fact measure mistakes not outcome results … such as discharges back to home and community based health services.  Jerry Rhoads